RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10028-1664 |
The Impact of the Over a Decade-long War in Syria on Dermatology Residents—A Cross-sectional Study: Part I—The Quality of Education and the Impact of the Deteriorating Economy
Faculty of Medicine, Cancer Research Center, Tishreen University, Latakia, Syrian Arab Republic
Corresponding Author: Jacob Al-Dabbagh, Faculty of Medicine, Cancer Research Center, Tishreen University, Latakia, Syrian Arab Republic, e-mail: jacobaldabbagh0@gmail.com
Received: 09 November 2023; Accepted: 12 April 2024; Published on: 05 July 2024
ABSTRACT
Introduction: Starting from 2011, the year that the war in Syria began, the health situation and medical education in Syria have deteriorated, including the training of doctors attending dermatology programs. Moreover, the onset of the coronavirus disease 2019 (COVID-19) pandemic has worsened the health situation and negatively impacted the training of resident doctors in Syria, including dermatology residents (DRs).
Aim and objective: This part of the study aims to assess the quality of dermatology training and identify the economic difficulties and challenges that residents faced during their residency period in the absence of necessary tools and expertise.
Materials and methods: Similar to the second part of the study, a web-based questionnaire was created in May 2023 and distributed electronically to dermatologists and doctors who joined the residency program (RP) in Syria at any time period from 2011 to 2023. Then, the participants’ data were recorded and analyzed.
Results: A total of 192 doctors (female, 167; male, 25), whose average age was 27.63, volunteered to participate in the study from 10 governorates in Syria. This part of the study indicated that there is no standardized dermatology training program for all institutions, which are also not equipped with the necessary tools and teaching methods. In addition, it shows that DRs are negatively affected by the deteriorated economic situation.
Conclusion: The dermatological residency programs in Syria must be developed to include all the necessary teaching tools and resources to improve the status of DRs and to familiarize them academically with the means of diagnosing and managing cutaneous disorders. Alternative educational curricula for DRs should also be developed, such as telemedicine, in case of the onset of unforeseen crises or outbreaks in order not to negatively affect their education.
How to cite this article: Al-Dabbagh J. The Impact of the Over a Decade-long War in Syria on Dermatology Residents—A Cross-sectional Study: Part I—The Quality of Education and the Impact of the Deteriorating Economy. J Postgrad Med Edu Res 2024;58(2):54–61.
Source of support: Nil
Conflict of interest: None
Keywords: Coronavirus disease 2019, Cross-sectional study, Dermatology, Economy, Medical education, Research, Resident doctors, Syria, Syrian war
INTRODUCTION
The Syrian crisis, which started in 2011, has had serious ramifications.1 The degradation of the health and education systems had a devastating effect both on the country and on its population.1 The management of the healthcare workers (HCWs) in Syria is complicated by the fractured health system, which has varying health and political leadership throughout the country.2 Moreover, the pandemic of coronavirus disease 2019 (COVID-19) presented a major challenge to the war-torn Syrian healthcare system, given the vulnerability of this system due to the lack of adequate equipment and the loss of about 70% of HCWs.3,4
The war in Syria has also led to an increase in skin diseases.5 Since 2011, an increase in cases of cutaneous leishmaniasis (CL) has been reported from multiple areas of Syria.5 The war also has led to outbreaks of cutaneous infections such as measles and scabies that have diffused through vulnerable populations in Syria and refugee camps in nearby countries.6
Dermatology represents one of the most competitive medical specialties.7 Dermatology residency training in Syria takes 4 years after graduation from medical school.8 The 1st year or the first several months of residency training usually consists of internal medicine, plastic surgery, and/or other medical specialties or does not consist of any of the other medical rotations except for dermatology.
Dermatology residents (DRs) normally receive their training in hospitals and centers affiliated with four ministries—the Ministry of Higher Education (MHE), the Ministry of Health (MH), the Ministry of Defense (MD), and the Ministry of Interior (MI). Upon completion of the training period, the residents are eligible to pass final examinations (written, clinical, and/or oral exams) and/or complete their master’s thesis, depending on the ministry to which their institution is affiliated.
This article attempts to assess the quality of training provided to DRs during the war in Syria and how they were affected by the deteriorating economic situation. Also, it investigates the perceptions of DRs in Syria about various aspects of their training and other issues related to dermatology.
This part of the study, in addition to the second part, is the first two articles concerned with the DRs in Syria, which discussed many aspects that had not been addressed before.
MATERIALS AND METHODS
This part of the study, along with the second part, followed the same materials and methods.
Design and Settings
An online questionnaire was developed via Google Forms, and the link was distributed nationwide through social media (snowball sampling) and sent to DRs/dermatologists who joined the residency program (RP) in Syria (through their dedicated social media groups). The questionnaire started on 14th May 2023 and closed on 16th June 2023.
Participants
The inclusion criteria were all doctors who practiced dermatology during their residency period or joined the RP from 2011 to the date that the questionnaire was developed in all hospitals or centers affiliated to MHE, MH, MD, and MI in all governorates in Syria in case they completed their residency period and became dermatologists or they still DRs or did not complete their residency period. Estimating the number of doctors that the study was designed to target is undoable, as there is no official data that provides either an exact or approximate number of them.
Questionnaire
The questionnaire was in Arabic and English. There were two types of questions in the questionnaire—open questions and multiple-choice questions. The questionnaire took about 9 minutes to complete.
The aspects which are discussed in this part of the study are—(1) demographics and information regarding the RP; (2) the most seen dermatology diseases; (3) cosmetic/dermatological procedures that were learned or performed; (4) A multiple-choice question that consists of many diverse attitudes related to the participants’ opinions on many issues; (5) economic situation; (6) the encountered challenges during COVID-19 waves; and (7) if the participants published a medical article in peer-reviewed journal.
Statistical Analysis
The responses were collected over 1 month, and the data was downloaded to Excel (Microsoft) for analysis. The statistical analysis was performed using IBM Statistical Package for the Social Sciences V.27. The data are presented as proportions and percentages. To determine differences between groups, the Chi-squared test was performed to compare categorical variables. A p-value of <0.05 was deemed statistically significant.
RESULTS
In total, 192 participants from 10 governorates to which their institutions belonged responded to the questionnaire. Data from doctors who joined the RP but still did not undergo full-time training in their dermatology department (DD) were excluded from some of the responses that requested sufficient experience and knowledge of the participants in the department. Nonetheless, no participants were excluded from the questionnaire since all questions, with the exception of some optional ones, had to be answered in order to submit the responses.
Demographics and Information Related to Residency Status
Over three quarters of the participants were females (86.97%, n = 167) and males were 13.02% (n = 25). The participants’ average age was 27.63 years. Of the participants, 17.71% (n = 34) completed their residency and became dermatologists, 4.17% (n = 8) quit their position and did not finish their RP, and 78.13% (n = 150) were still DRs at the time of the start of this study; 10.66% (n = 16) of them were in their first year of residency, 41.33% (n = 62) were in their 2nd year, 26% (n = 39) were in their 3rd year, 18.66% (n = 28) were in their 4th year, and 3.33% (n = 5) started their residency but were still practicing in other departments and/or not receiving full-time training.
The number and percentage of the participants who joined the RP based on the year they started their residency is demonstrated in the following chart (Fig. 1).
Fig. 1: The number and percentage of participants who were accepted as DRs in the year in which they began their residency
Participants from institutions belonging to four ministries (MHE, MH, MD, and MI) responded to the questionnaire. The percentage and number of participants based on the MHE institutions to which they belonged are as follows—21 (10.93%) from Lattakia (Tishreen University), 20 (10.41%) from Damascus (Damascus University), and 11 (5.72%) from Aleppo (University of Aleppo). For participants whose institutions belonged to the MH, they are as follows—28 (14.58%) from Damascus, 26 (13.54%) from Lattakia, 19 (9.89%) from Aleppo, 19 (9.89%) from Tartous, 15 (7.81%) from Homs, 13 (6.77%) from Hama, 5 (2.60%) from Quneitra, 3 (1.56%) from Al-Hasakah, 3 (1.56%) from As-Suwayda, and 1 (0.52%) from Daraa. Regarding participants affiliated with institutions that belong to MD, 6 (3.12%) were from Damascus, and 1 (0.52%) was from Homs. In addition, only one participant (0.52%) was affiliated with institutions belonging to MI, which were in Damascus. The number of participants by the institutions to which they were affiliated within the governorates is shown in the following illustrated map (Fig. 2). No doctors whose institutions belonged to Idlib, Raqqa, Deir ez-Zor, or Rif Dimashq participated.
Fig. 2: The number of participants according to the institutions they belonged to in each governorate
The Most-seen Cutaneous Diseases
This section includes an open-ended question about the most common diseases that participants faced during their residency in the DD. Responses included one disease or multiple diseases. However, the number of the most frequently seen diseases in each response was counted, whether it was the only disease or one of multiple diseases. Responses of 2.60% (n = 5) of the participants were excluded because they were still rotating in other departments and/or not receiving full-time training.
The number and percentage of the most frequently seen skin diseases are as follows—scabies 53.47% (n = 100), warts 26.20% (n = 49), CL 22.45% (n = 42), tinea 15.50% (n = 29), pediculosis 10.16% (n = 19), acne 8.02% (n = 15), psoriasis 6.95% (n = 13), and eczema 6.41% (n = 12).
Performing Cosmetic/Dermatological Procedures
In this section, participants responded to the following three questions—the first question is about which of the following cosmetic/dermatological procedures the participants learned or practiced at their institutions during their residency period—filler injection, botulinum toxin injections, thread lift, hair transplant, sclerotherapy, lasers, soft tissue augmentation, chemical peels, liposuction, scar revision, dermabrasion, and Mohs surgery. The second question is about which of the abovementioned cosmetic/dermatological procedures the participants learned or practiced outside their institutions at other centers while they were still DRs. The third question was an open-ended question about why the participants were not taught how to perform cosmetic procedures, in case they were not, within their institutions based on their opinions.
Around 2.60% (n = 5) of participants who were still rotating in other medical departments or/and not receiving full-time training did not learn/perform any of these procedures either in their institution or outside it; thus, their answers were not included.
The Results of the First Question
Around 68.75% (n = 132) of the participants did not learn or practice any of the previous procedures during their residency period in their institutions. On the contrary, 28.64% (n = 55) of them learned or participated in at least one of these procedures. The procedures practiced by the participants within their institutions, from the most common to the least common, are as follows—lasers (n = 29), chemical peels (n = 26), botulinum toxin injections (n = 25), filler injection (n = 14), thread lift (n = 14), scar revision (n = 9), Mohs surgery (n = 4), and dermabrasion (n = 2). No participants were taught or practiced any of the following procedures in their institutions—soft tissue augmentation, sclerotherapy, dermabrasion, hair transplant, or liposuction (Fig. 3A). The types of these procedures were significantly varied according to each RP (p < 0.001).
Figs 3A and B: Number and percentage of cosmetic/dermatologic procedures by type learned and practiced by participants during their RP (A) within or (B) outside their institutions
The Results of the Second Question
Around 40.10% (n = 77) of the participants did not learn or practice any of the previous procedures during their residency period outside their institution, while 57.29% (n = 110) of them learned or participated in at least one of the procedures.
The procedures that participants practiced outside their institutions during their residency period, in order of most common to least common, are as follows—botulinum toxin injections (n = 85), lasers (n = 74), filler injection (n = 58), chemical peels (n = 40), thread lift (n = 39), dermabrasion (n = 27), scar revision (n = 24), soft tissue augmentation (n = 11), Mohs surgery (n = 5), hair transplant (n = 5), sclerotherapy (n = 5), and liposuction (n = 4) (Fig. 3B).
Around 29.41% (n = 56) of the participants did not learn or practice any of the aforementioned procedures, neither within their institution nor outside it, during their residency.
Participants who practiced or learned at least one of the abovementioned procedures belonged only to the following institutions—the hospital of Tishreen University, the hospital of Damascus University, the hospital of the University of Aleppo, and hospitals/centers affiliated to MH in Damascus and Aleppo. According to the participants’ responses, the remaining institutions have not taught or trained any of the previous procedures.
The Answers to the Third Question
Around 32.29% (n = 62) of the participants answered the following question “Why do you think you were not taught how to perform any of the cosmetic procedures in your department?” Since this was an open-ended question, there were many different responses based on each participant’s personal opinion, despite their similarities and the resemblance on many points, such as the lack of capabilities and financial support. A participant from Tishreen University had the following opinion—“There is no support for establishing a dedicated department for teaching cosmetic procedures in our institution. Currently, it is not possible to learn or practice these procedures unless they are performed independently outside of our department.” From the hospitals/centers affiliated with the MH in Damascus there were many responses, including these statements “Because there are no directives from the MH or Higher Education to supervisors and specialists to teach DRs these procedures. In addition, there is no funding from these ministries. Therefore, residents learn these procedures independently outside their institutions, although they cannot afford the full expenses of them.” “Because DRs are considered strong competitors to dermatologists, especially with the presence of social media and marketing methods that are lacking by dermatologists, especially the elderly, compared to the residents who can use these platforms and marketing methods to promote themselves,” and “Because these procedures are not formally included in the training programs for dermatology in Syria and due to the lack of sufficient financial support, also, the decision to teach these procedures is up to the supervisors.” A participant from the hospitals/centers affiliated to the MH in Tartous responded, “There is no reason why these skills cannot be learned. It is necessary to learn them in our area of expertise, and we do not know why this important aspect is neglected in our institutions.” Another response “Due to the lack of the necessary resources to practice cosmetic procedures in our institution, and considering cosmetic dermatology as a subspecialization of dermatology. Also, supervisors always focus on dermatology as a medical specialty. In any case, these procedures may be learned outside the institution” from a participant who belonged to the hospitals/centers affiliated to the MH in Homs. Another participant, who was from the hospitals/centers affiliated with the MH in Lattakia, responded, “Due to the unwillingness of supervisors to perform these procedures and the lack of the necessary materials and skills.” Two responses were given by participants from the hospitals/centers affiliated with the MH in Aleppo “Due to the lack of financial capabilities to purchase the materials and equipment needed for training” and “The institution is not qualified, either financially or technically, to teach these cosmetic procedures, and the building of the institution to which we belong is dilapidated and the departments are not suitable for such procedures.”
Participants’ Opinions on Various Aspects Related to Multiple Issues and Challenges They Faced
This section consists of many points on which participants were asked to express their opinions if they agreed or disagreed. The points addressed were related to the following aspects—the quality of the resident’s training and education and the availability of the required tools and skills for their training, the difficulties related to the cosmetic workshops attended by the residents, the status of dermatological drugs in Syria in terms of efficacy and availability, the status and importance of cosmetic dermatology compared to dermatological medicine, the incidence of the variety of skin diseases seen by the DRs in their institutions, and the professional status of the DRs in case of publication of medical articles.
The items addressed in this section and the number and percentage of participants who agreed or disagreed with them are listed in Table 1.
| Item | Description | Agree n (%) | Disagree n (%) |
|---|---|---|---|
| 1 | The medical information and clinical training that DRs normally receive (or have received) at my institution are not sufficient to make me familiar with most dermatological diseases and therapeutic interventions upon completion of the residency period | 99 (51.6%) | 93 (48.4%) |
| 2 | A standardized protocol is not followed in my institution for the diagnosis and management of skin disorders | 86 (44.8%) | 106 (55.2%) |
| 3 | The equipment and tools that are available in my institution are not sufficient for diagnosing and treating most skin diseases | 129 (67.2%) | 63 (32.8%) |
| 4 | Cosmetic courses and workshops attended by DRs outside their institutions are very expensive, and not everyone can participate in them | 172 (89.6%) | 20 (10.4%) |
| 5 | There is a shortage of dermatological drugs and supplies in Syria, in addition to a constant increase in their prices | 128 (66.7%) | 64 (33.3%) |
| 6 | Most of the national dermatological drugs are of poor quality and do not achieve effective treatment | 61 (31.8%) | 131 (68.2%) |
| 7 | Dermatology is the most competitive specialty among other specialties in Syria | 134 (69.8%) | 58 (30.2%) |
| 8 | Dermatologists in Syria practice cosmetic dermatology more than medical dermatology | 119 (62%) | 73 (38%) |
| 9 | Dermatologists in Syria cannot have a good financial return without practicing cosmetic dermatology | 147 (76.6%) | 45 (23.4%) |
| 10 | The number and variety of clinical cases in my institution are not enough to make the dermatology resident familiar with most skin diseases | 65 (33.9%) | 127 (66.1%) |
| 11 | The majority of DRs work overtime in cosmetic centers where they practice cosmetic dermatology in order to increase their financial returns | 138 (71.9%) | 54 (28.1%) |
| 12 | Medical articles and case reports published by resident doctors do not raise the resident’s salary or improve his/her academic situation within his/her institution in Syria | 118 (61.5%) | 74 (38.5%) |
Economic Issues
This section involves the following question “How long can the monthly salary that you receive (or have received) as a resident at your institution usually last/lasted?” which was answered based on the number and percentage of the participants as follows—<3 days (n = 80, 41.66%); between 3 and 5 days (n = 35, 18.22%); between 5 and 7 days (n = 41, 21.35%); and >1 week (n = 22, 11.45%). However, 14 participants (7.29%) do not receive any salary; instead, they pay fees to their institutions for being DRs.
Challenges and Residency Situation during COVID-19 Waves
The responses of 78 participants (40.62%) were excluded since they declared that no COVID-19 waves occurred during their RP. Also, responses of participants who were accepted in the RP but were still rotating in other medical departments or/and not receiving full-time training were also excluded.
The participants answered the following questions—(1) Were your medical education and training negatively affected during your residency by the waves of COVID-19? (2) Have the clinical activities of DRs been suspended in your institution during COVID-19 waves? and (3) Have the clinical activities of DRs during COVID-19 waves been replaced by telemedicine?
The answers of 114 participants (59.37%) were analyzed. The answers based on the order of each question were as follows—(1) 77 participants (67.54%) declared that their medical education and training were negatively affected, whereas 37 (32.45%) stated that they were not; (2) the clinical activities of 78 participants (68.42%) were suspended, while the clinical activities of 36 (31.57%) were not; and (3) this question was answered “No” by 79 participants (69.29%), while 35 participants (30.70%) answered ”Yes”.
Publishing in a Peer-reviewed Journal
This section includes a question about whether the participants have published at least one medical article in a peer-reviewed journal. The vast majority of participants, 93.75% (n = 180), have not published any medical article, whereas only 12 participants (6.25%) have published at least one medical article. Three participants have published at least one article before joining their RP, eight have published during their residency period, and only one participant has published after his/her residency period (Fig. 4).
Fig. 4: The percentage of participants who did not publish or published at least one medical article before, during, or after their residency period
DISCUSSION
The conflict in Syria, which began in March 2011, has had a negative impact on the education and training of HCWs, in turn affecting their skills, number, and distribution as they enter the workforce.2 Besides the lack of medical equipment and medicines, several health facilities have been completely destroyed.9 The migration of many experienced academics has left fewer highly qualified specialists available to mentor the training of younger doctors.10
A study conducted among resident doctors (RDs) in Syria to investigate the knowledge, attitude, and practice of evidence-based medicine between September 2021 and February 2022 showed that more than half of the residents (55.1%) had a low level of knowledge, followed by a medium level of knowledge (35%).11 Nevertheless, a limited number (9.8%) had a high-level of knowledge.11 Most residents had a poor (68.2%) followed by a fair (23.4%) level of practice.11 Whereas, only 8.4% were identified as having a good level of practice.11 Additionally, the general impression of evidence-based medicine among them showed a neutral attitude.11
As a result of the conflict in Syria, the RPs of dermatology have also been negatively affected, with 51.6% of the participants considering that the medical information and clinical training received in their institutions are not adequate to familiarize them with the majority of skin diseases and their management. In addition, 67.2% stated that there are not enough tools in their institution to diagnose and treat the majority of skin diseases. Around 44.8% of the respondents also stated that no standard protocol is followed in their facilities for the diagnosis and treatment of skin diseases.
There has been a significant increase in the number of patients seeking cosmetic surgery in the last several years, with a trend toward performing more cosmetic procedures in the dermatology clinic.12 Advances in cosmetic surgery have become increasingly evident in recent years, especially with laser surgery, botulinum toxin injections, soft tissue augmentation, chemical peels, hair transplantation, and rhytidectomy.13 Around 62% of the participants agree that dermatologists in Syria practice more cosmetic dermatology than medical dermatology. However, learning and practicing cosmetic dermatology was also negatively affected in Syria. Around 68.75% of the participants who joined full-time training did not learn or practice any of the following procedures during their residency at their institutions—filler injection, botulinum toxin injections, thread lift, hair transplant, sclerotherapy, lasers, soft tissue augmentation, chemical peels, liposuction, scar revision, dermabrasion, and Mohs surgery. In contrast, 28.64% of them learned or practiced at least one of these procedures.
Procedures practiced by the participants at their facilities, ranging from most frequent to least frequent, were as follows—laser, chemical peels, botulinum toxin injections, filler injections, thread lift, scar revision, Mohs surgery, and dermabrasion. None of the participants learned or practiced any of the following procedures at their facilities—soft tissue augmentation, sclerotherapy, dermabrasion, hair transplantation, or liposuction. On the contrary, 40.10% of the respondents who joined full-time training have not learned or practiced any of these procedures during their residency training outside of their institution, while 29.41% did not learn or practice any of them during their residency training, either inside or outside of their institutions. Therefore, residents had to attend courses and workshops outside their institution to receive proper education and training to practice these procedures. In any case, 89.6% of the participants agree that these workshops and courses are very expensive and not everyone can afford them.
Based on a survey conducted in the United States among DRs in 2011, 79.7% of the residents reported attending formal cosmetic hands-on training courses where they learn to perform cosmetic procedures on patients.12 The majority of residents have the opportunity to perform botulinum toxin injections (93.2%), laser surgery (92.4%), fillers (83.1%), chemical peels (70.3%), and sclerotherapy (70.3%) during residency training.12 The study also found that the majority of RPs encourage or fairly encourage their residents to perform cosmetic procedures with proper training.12 Another study published in 2018 which assisted the training in the field of cosmetic dermatology among DRs in the USA and Canada has shown that most residents (94%) received didactic education on cosmetic dermatology topics from main faculty members and/or other presenters, and 91% of them obtained hands-on training in cosmetic procedures during their residency.14 In comparison with an Arab country, a study was conducted in 2020 to assess the experience of DRs and dermatologists with cosmetic dermatology training in Saudi Arabia has found that laser surgery was the most frequently performed procedure (65%), followed by botulinum toxin injection (50%) and chemical peels (26%).13 However, 90% of the respondents felt that they had not received appropriate training in esthetic procedures during their RP.13 Also, 91% planned to perform and incorporate esthetic procedures into their practice after completing RPs.13 A significant percentage of respondents agreed (33%) or strongly agreed (59%) that a structured cosmetic procedures curriculum would enhance their residency education.13
In addition to the negative impact of the war on medical education and training, the war in Syria has also established ideal conditions allowing for the spread and outbreak of infectious diseases.15 The disruption of the vaccination program, the destruction of health facilities, the emigration of HCWs, and the mass displacement of refugees to other countries and living without adequate healthcare in refugee camps have been important reasons for the spread of infectious diseases, such as tuberculosis, leishmaniasis, hepatitis, polio, measles, and other infectious diseases among both refugees and host communities.15 Skin diseases, such as CL, scabies, and pediculosis, continue to affect an increasingly vulnerable population.6 The war in Syria is associated with an increasing number of risk factors for CL, such as reduced preventive measures, limited access to diagnosis and treatment, destroyed infrastructure, population movements, and deteriorating living conditions, including overcrowding.5 The aftermath of the war is also reflected in the types of diseases most commonly seen, with infectious diseases, such as scabies (53.47%), warts (26.20%), CL (22.45%), tinea (15.50%), and pediculosis (10.16%) listed among the most commonly reported diseases by the participants. Anyhow, 66.1% of participants disagreed that the number and variety of clinical cases at the institution to which they belong/belonged does not make them familiar with most skin diseases.
Before the crisis, public hospitals in Syria were an essential part of the country’s healthcare system, providing patients with accessible, low-cost, or free treatment for long-term medical conditions.4 The war led to a lack of drugs and medical supplies as the Syrian economy worsened dramatically and poverty became more rampant.16 However, Syria and Yemen had the lowest healthcare expenditure per capita in the Middle East/North Africa region based on a study that used annual time series data on healthcare expenditure and outcomes from 1995 to 2015.17 Around 66.7% of participants agree that there is a shortage of dermatological medicines in Syria and their prices are constantly increasing. In addition, 31.8% agree that most national dermatological medicines are of poor quality and do not provide effective treatment. As a result, this can lead to serious consequences on the patient’s health and management. Drug shortages could lead to an increased risk of drug overdose due to changes in the concentration and strength of the drug.18 In addition, the prescribed alternative drug might be less effective or may put the patient at higher risk of unwarranted side effects.18
The COVID-19 pandemic posed additional challenges to the Syrian health system, which has also impacted the quality of education/training provided to DRs. By the end of March, the Syrian government’s response to the pandemic began with a complete lockdown of the country.15 However, the health quarantine ended up lasting 2 months but had a serious impact on the economic situation of the country.15 As a result, restrictions were withdrawn in June, leading to an increase in the number of cases of the disease and the mortality rate among the population.15
COVID-19 forced a total paradigm shift in medical education, introducing new learning models and opening up unimagined educational options within and outside of the field of dermatology.19 According to participants who were DRs during the COVID-19 pandemic, 68.42% of them declared that the clinical activities in their department were suspended during COVID-19 waves. Also, 67.54% of them stated that their medical education and training were negatively affected, and 69.29% declared that their clinical activities were not replaced by telemedicine during the COVID-19 waves.
As of April 2020, 90% of DRs practicing in the United States believed that COVID-19 had negatively impacted their training, although 92% still believed that remote learning was beneficial.19 According to guidelines from the Centers for Disease Control and Prevention and the American Academy of Dermatology, many dermatology programs and practices transitioned to telemedicine to reduce personal exposure, maintain critical supplies of personal protective equipment, and limit disease transmission at the onset of the COVID-19 pandemic.19 However, some learning experiences, such as dermatopathology and dermatologic surgery, are more challenging to learn in a virtual setting.19
The results of my study also showed that the vast majority of participants (93.75%) did not publish medical articles in peer-reviewed journals before, during, or after their RP. However, 61.5% of them believe that publishing medical papers does not raise the residents’ salaries or improve their academic situation.
Based on a review of National Resident Matching Program outcomes between 2007 and 2019 in the United States of America (USA), dermatology residency applicants who had more publications and research projects were found to be more likely to match than applicants who had fewer publications and research projects.7 Applicants to dermatology in the USA have, on average, the highest number of publications and research experience among all specialties.20 In any case, the publication of medical papers does not play a role in the admission of newly graduated doctors in Syria to any of the RPs. In addition to the neglect of this academic aspect in Syria even before the war. A study conducting a scoping review of Syrian health-related articles between 1991 and 2017, in addition to another study performed a comprehensive review of the literature from 1980 to 2011 published by authors affiliated with Syrian institutions, revealed a high deficit in the research productivity of the Syrian medical community.21,22 Compared to neighboring Arab and non-Arab Middle Eastern countries, Syrian scholars publish far less.22 In addition, the quality of reported publications is low, as determined by the type of publications, citation frequency, and impact factors of published journals.22
The shortage of research productivity in the Syrian medical sector has many causes; first and foremost, there is a lack of educational materials for research and a support system at the medical school level.23 The negative impact of the Syrian war was also reflected in the types of articles and the topics and aspects they covered.21 There was an increase in mental health, accidents and injuries, and health and conflict articles in the in-conflict period.21
Around 81.23% of the participants in my study stated that their monthly salary is not enough for >1 week. In addition, 7.29% of them pay fees to their institutions for joining the RP. Also, 71.9% of the participants believe that most DRs work overtime in cosmetic centers to increase their financial income. Furthermore, 76.6% of them believe that dermatologists in Syria cannot get a good financial return without performing cosmetic procedures.
Wages and salaries in the public sector are very low, especially in light of the inflation plaguing the country.16 Many RDs in Syria stated that they have additional jobs or depend on financial support from their families.24 However, if the RDs practice their profession outside the centers and hospitals of the institutions to which they belong, whether during official or unofficial hours, without getting formal, they will be punished with direct dismissal.25
The study’s limitation is that it did not address the marital status of the participants during their residency in the DD in order to assess a link between their marital status and the other aspects investigated in the study.
CONCLUSION
The educational programs of dermatology vary among institutions in Syria, which are not all able to sustain a standardized level of proficiency, especially with the existence of the difficulties and challenges affecting healthcare and educational systems since the beginning of the war in 2011 through COVID-19 pandemic that occurred in 2020 in Syria. The war has also led to outbreaks of infectious diseases, which have affected the most commonly seen skin diseases by DRs. Around 67.54% of the participants who were DRs during the COVID-19 pandemic stated that their medical education and training were negatively affected, and 69.29% of them indicated that their training was not replaced by telemedicine during the pandemic. In addition, most facilities that DRs belong to do not offer training or educational courses for many cosmetic and dermatological procedures; therefore, DRs are somehow pressured to attend courses outside of their facilities to increase their expertise and learn such procedures, which can be very expensive and cannot be afforded by everyone. However, if DRs practice cosmetic/dermatological procedures or work additional time to gain additional income outside of their institution, they face dismissal. Therefore, DRs are restricted to working only within their facilities, and they cannot expand their area of expertise and work outside of the facilities unless they work illegally.
Dermatology residents, as well as other RDs, are victims of many political, economic, and health crises that have occurred in Syria, which have negatively impacted their education and training.
Health and education systems in Syria should intensify their efforts to improve the situation of DRs, provide them with the necessary tools and expertise, and establish a standardized education system for all the residents. RPs should periodically assess and modify their curriculum to ensure that their residents are being adequately trained. Formal training sessions are an excellent way for DRs to gain experience performing cosmetic/dermatological procedures. Supervisors and medical specialists should also offer adequate support to RDs and medical students and encourage them to publish in peer-reviewed scientific journals.
ORCID
Jacob Al-Dabbagh https://orcid.org/0000-0002-5596-9738
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